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Free Alaska Advance Directive for Health Care (Alaska Living Will) Form - PDF Form Download

Alaska Advance Directive for Health Care (Alaska Living Will) Form
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Download and Print this form if you want to make your Living Will in the State of Alaska.


Alaska Advance Directive for Health Care Form

Text Version of this Form

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Advance Directives for Health Care
&
Mental Health Care

for

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ADVANCE HEALTH CARE DIRECTIVE

EXPLANATION

You have the right to give instructions about your own health care to the extent allowed
by law. You also have the right to name someone else to make health care decisions for you to
the extent allowed by law. This form lets you do either or both of these things. It also lets you
express your wishes regarding the designation of your health care provider. If you use this
form, you may complete or modify all or any part of it. You are free to use a different form if
the form complies with the requirements of AS 13.52.

Part 1 of this form is a durable power of attorney for health care. A “durable
power attorney for health care” means the designation of an agent to make health care
decisions for you. Part 1 lets you name another individual as an agent to make health care
decisions for you if you do not have the capacity to make your own decisions or if you want
someone else to make those decisions for you now even though you still have the capacity to
make those decisions. You may name an alternate agent to act for you if your first choice is not
willing, able, or reasonably available to make decisions for you. Unless related to you, your
agent may not be an owner, operator, or employee of a health care institution where you are
receiving care.

Unless the form you sign limits the authority of your agent, your agent may make all
health care decisions for you that you could legally make for yourself. This form has a place for
you to limit the authority of your agent. You do not have to limit the authority of your agent if
you wish to rely on your agent for all health care decisions that may have to be made.
If you choose not to limit the authority of your agent, your agent will have the right, to
the extent allowed by law, to
(a) consent or refuse consent to any care, treatment, service, or procedure to
maintain, diagnose, or otherwise affect a physical or mental condition, including the
administration or discontinuation of psychotropic medication;
(b) select or discharge health care providers and institutions;
(c) approve or disapprove proposed diagnostic tests, surgical procedures, and
programs of medication; and
(d) direct the provision, withholding, or withdrawal of artificial nutrition and
hydration and all other forms of health care; and
(e) make an anatomical gift following your death.

Part 2 of this form lets you give specific instructions for any aspect of your
health care to the extent allowed by law, except you may not authorize mercy killing,
assisted suicide, or euthanasia.
Choices are provided for you to express your wishes regarding the provision, withholding,
or withdrawal of treatment to keep you alive, including the provision of artificial nutrition and
hydration, as well as the provision of pain relief medication. Space is provided for you to add to
the choices you have made or for you to write out any additional wishes.

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Part 3 of this form lets you express an intention to make an anatomical gift
following your death.

Part 4 of this form lets you make decisions in advance about certain types of
mental health treatment.

Part 5 of this form lets you designate a physician to have primary responsibility
for your health care.

After completing this form, sign and date the form at the end and have the form
witnessed by one of the two alternative methods listed below. Give a copy of the signed and
completed form to your physician, to any other health care providers you may have, to any
health care institution at which you are receiving care, and to any health care agents you have
named. You should talk to the person you have named as your agent to make sure
that the person understands your wishes and is willing to take the responsibility.

You have the right to revoke this advance health care directive or replace this
form at any time, except that you may not revoke this declaration when you are determined not
to be competent by a court, by two physicians, at least one of whom shall be a psychiatrist, or
by both a physician and a professional mental health clinician.

In this advance health care directive, “competent” means that you have the capacity
(1) to assimilate relevant facts and to appreciate and understand your situation
with regard to those facts; and
(2) to participate in treatment decisions by means of a rational thought process.

The form that follows is found in AS 13.52.300

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PART 1

DURABLE POWER OF ATTORNEY
FOR
HEALTH CARE DECISIONS

(1) DESIGNATION OF AGENT.

I designate the following individual as my agent to make health care decisions for me:

Name
Address
City State Zip
Home Phone Work

OPTIONAL: If I revoke my agent’s authority or if my agent is not willing,
able, or reasonably available to make a health care decision for me,
I designate as my first alternate agent:

Name
Address
City State Zip
Home Phone Work

OPTIONAL: If I revoke the authority of my agent and first alternate agent
or if neither is willing, able, or reasonably available to make a health care decision for me,
I designate as my second alternate agent:

Name
Address
City State Zip
Home Phone Work

(2) AGENT’S AUTHORITY.

My agent is authorized and directed to follow my individual instructions and my other
wishes to the extent known to the agent in making all health care decisions for me. If these are
not known, my agent is authorized to make these decisions in accordance with my best interest,
including decisions to provide, withhold, or withdraw artificial hydration and nutrition and
other forms of health care to keep me alive, except as I state here:
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________

(Add additional sheets if needed.)

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Under this authority, “best interest” means that the benefits to you resulting from a
treatment outweigh the burdens to you resulting from that treatment after assessing
(A) the effect of the treatment on your physical, emotional, and cognitive
functions;
(B) the degree of physical pain or discomfort caused to you by the treatment or the
withholding or withdrawal of treatment;
(C) the degree to which your medical condition, the treatment, or the withholding
or withdrawal of treatment, results in a severe and continuing impairment;
(D) the effect of the treatment on your life expectancy;
(E) your prognosis for recovery, with and without the treatment;
(F) the risks, side effects, and benefits of the treatment or the withholding of
treatment; and
(G) your religious beliefs and basic values, to the extent that these may assist in
determining benefits and burdens.

(3) WHEN AGENT’S AUTHORITY BECOMES EFFECTIVE .

Except in the case of mental illness, my agent’s authority becomes effective
when my primary physician determines that I am unable to make my own health
care decisions unless I mark the following box.
In the case of mental illness, unless I mark the following box, my agent’s authority
becomes effective when a court determines I am unable to make my own decisions, or, in an
emergency, if my primary physician or another health care provider determines I am unable to
make my own decisions.

If I mark this box [ ], my agent’s authority to make health care decisions for me
takes effect immediately.

(4) AGENT’S OBLIGATION.

My agent shall make health care decisions for me in accordance with this durable
power of attorney for health care, any instructions I give in Part 2 of this form, and my other
wishes to the extent known to my agent. To the extent my wishes are unknown, my agent
shall make health care decisions for me in accordance with what my agent determines to be in
my best interest. In determining my best interest, my agent shall consider my personal values
to the extent known to my agent.

(5) NOMINATION OF GUARDIAN.

If a guardian of my person needs to be appointed for me by a court, I nominate the
agent designated in this form. If that agent is not willing, able, or reasonably available to act
as guardian, I nominate the alternate agents whom I have named under (1) above, in the order
designated.

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PART 2

INSTRUCTIONS FOR HEALTH CARE

If you are satisfied to allow your agent to determine what is best for you in
making health care decisions, you do not need to fill out this part of the form.

If you do fill out this part of the form, you may strike any wording you do not want.
There is a state protocol that governs the use of do not resuscitate orders by physicians and
other health care providers. You may obtain a copy of the protocol from the Alaska
Department of Health and Social Services. A “do not resuscitate order” means a directive from
a licensed physician that emergency cardiopulmonary resuscitation should not be administered
to you.

(6) END-OF-LIFE DECISIONS.

Except to the extent prohibited by law, I direct that my health care providers and
others involved in my care provide, withhold, or withdraw treatment in
accordance with the choice I have marked below: (Check only one box.)

[ ] (A) Choice To Prolong Life I want my life to be prolonged as long as
possible within the limits of generally accepted health care standards; OR

[ ] (B) Choice Not To Prolong Life I want comfort care only and I do not want
my life to be prolonged with medical treatment if, in the judgment of my physician, I
have (check all choices that represent your wishes)

[ ] a condition of permanent unconsciousness: a condition that, to a
high degree of medical certainty, will last permanently without
improvement; in which, to a high degree of medical certainty, thought,
sensation, purposeful action, social interaction, and awareness of myself
and the environment are absent; and for which, to a high degree of medical
certainty, initiating or continuing life-sustaining procedures for me, in light
of my medical outcome, will provide only minimal medical benefit for me;
or
[ ] a terminal condition: an incurable or irreversible illness or injury
that without the administration of life-sustaining procedures will result in
my death in a short period of time, for which there is no reasonable
prospect of cure or recovery, that imposes severe pain or otherwise imposes
an inhumane burden on me, and for which, in light of my medical condition,
initiating or continuing life-sustaining procedures will provide only
minimal medical benefit;

[ ] additional instructions:
_________________________________________________________________
_________________________________________________________________

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(C) Artificial Nutrition and Hydration. If I am unable to safely take
nutrition, fluids, or nutrition and fluids (check your choices or write your instructions),

[ ] I wish to receive artificial nutrition and hydration indefinitely;

[ ] I wish to receive artificial nutrition and hydration indefinitely, unless it
clearly increases my suffering and is no longer in my best interest;

[ ] I wish to receive artificial nutrition and hydration on a limited trial
basis to see if I can improve;

[ ] In accordance with my choices in (6)(B) above, I do not wish to receive
artificial nutrition and hydration.

[ ] Other instructions

(D) Relief from Pain.

[ ] I direct that adequate treatment be provided at all times for the sole
purpose of the alleviation of pain or discomfort; or

[ ] I give these instructions:

(E) Should I become unconscious and I am pregnant,

I direct that

(7) OTHER WISHES. (If you do not agree with any of the optional choices above
and wish to write your own, or if you wish to add to the instructions you have
given above, you may do so here.)

I direct that
________________________________________________________________ _
___________________________________________________________________

Conditions or limitations:

(Add additional sheets if needed.)

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PART 3

ANATOMICAL GIFT AT DEATH
(OPTIONAL)

If you are satisfied to allow your agent to determine whether to make an
anatomical gift at your death, you do not need to fill out this part of the form.

(8) UPON MY DEATH: (mark applicable box)

[ ] (A) I give any needed organs, tissues, or other body parts,
OR
[ ] (B) I give the following organs, tissues, or other body parts only:
______________________________________________________________________________

My gift under (A) or (B) above is for the following purposes (mark any of the following
you want):
[ ] transplant;
[ ] therapy;
[ ] research;
[ ] education.

[ ] (C) I refuse to make an anatomical gift.

PART 4

MENTAL HEALTH TREATMENT
(OPTIONAL)

This part of the declaration allows you to make decisions in advance about mental
health treatment.
The instructions that you include in this declaration will be followed only if a court,
two physicians that include a psychiatrist, or a physician and a professional mental
health clinician believe that you are not competent and cannot make treatment
decisions. Otherwise, you will be considered to be competent and to have the capacity to give
or withhold consent for the treatments.

If you are satisfied to allow your agent to determine what is best for you in
making these mental health decisions, you do not need to fill out this part of the
form. If you do fill out this part of the form, you may strike any wording you do not want.

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(9) PSYCHOTROPIC MEDICATIONS. If I do not have the capacity to give or
withhold informed consent for mental health treatment, my wishes regarding psychotropic
medications are as follows:

[ ] I consent to the administration of the following medications:
________________________________________________________________________

[ ] I do not consent to the administration of the following medications:
________________________________________________________________________

Conditions or limitations:

(10) ELECTROCONVULSIVE TREATMENT. If I do not have the capacity to
give or withhold informed consent for mental health treatment, my wishes regarding
electroconvulsive treatment are as follows:

[ ] I consent to the administration of electroconvulsive treatment.

[ ] I do not consent to the administration of electroconvulsive treatment.

Conditions or limitations:

___________________________________________________________________

(11) ADMISSION TO AND RETENTION IN FACILITY. If I do not have the
capacity to give or withhold informed consent for mental health treatment, my
wishes regarding admission to and retention in a mental health facility for
mental health treatment are as follows:

[ ] I consent to being admitted to a mental health facility for mental health
treatment for up to ________ days. (The number of days not to exceed 17.)

[ ] I do not consent to being admitted to a mental health facility for mental
health treatment.

Conditions or limitations:

___________________________________________________________________

OTHER WISHES OR INSTRUCTIONS

Conditions or limitations:

___________________________________________________________________

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PART 5

PRIMARY PHYSICIAN
(OPTIONAL)

(12) I DESIGNATE THE FOLLOWING PHYSICIAN AS MY
PRIMARY PHYSICIAN:

Name of Physician
Address
City State Zip
Phone

OPTIONAL: If the physician I have designated above is not willing, able, or reasonably
available to act as my primary physician, I designate the following physician as my primary
physician:

Name of Physician
Address
City State Zip
Phone

(13) EFFECT OF COPY. A copy of this form has the same effect as the original.

(14) SIGNATURES.

In the presence of the witnesses or notary public, sign and date the form here:

Signature Date

Printed Name

Address
City State Zip

(15) WITNESSES.

This advance care health directive will not be valid for making health care decisions
unless it is

(A) signed by two (2) qualified adult witnesses who are personally known to
you and who are present when you sign or acknowledge your signature;
the witnesses may not be a health care provider employed at the health

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care institution or health care facility where you are receiving health
care, an employee of the health care provider who is providing health
care to you, an employee of the health care institution or health care
facility where you are receiving health care, or the person appointed as
your agent by this document; at least one of the two witnesses may not
be related to you by blood, marriage, or adoption or entitled to a portion
of your estate upon your death under your will or codicil; or

(B) acknowledged before a notary public in the state.

ALTERNATIVE NO. 1

WITNESS WHO IS NOT RELATED TO OR A DEVISEE OF THE PRINCIPAL:

I swear under penalty of perjury under AS 11.56.200 that the principal is
personally known to me, that the principal signed or acknowledged this durable power of
attorney for health care in my presence, that the principal appears to be of sound mind and
under no duress, fraud, or undue influence, that I am not
(1) a health care provider employed at the health care institution or health care
facility where the principal is receiving health care;
(2) an employee of the health care provider providing health care to the principal;
(3) an employee of the health care institution or health care facility where the
principal is receiving health care;
(4) the person appointed as agent by this document;
(5) related to the principal by blood, marriage, or adoption; or
(6) entitled to a portion of the principal’s estate upon the principal’s death under a
will or codicil.

Signature of First Witness Date

Printed Name
Address
City State Zip

WITNESS WHO MAY BE RELATED TO OR A DEVISEE OF THE PRINCIPAL

I swear under penalty of perjury under AS 11.56.200 that the principal is personally
known to me, that the principal signed or acknowledged this durable power of attorney for
health care in my presence, that the principal appears to be of sound mind and under no
duress, fraud, or undue influence, that I am not
(1) a health care provider employed at the health care institution or health care facility
where the principal is receiving health care;
(2) an employee of the health care provider who is providing health care to the principal;

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(3) an employee of the health care institution or health care facility where the principal
is receiving health care; or
(4) the person appointed as agent by this document.

Signature of Second Witness Date

Printed Name
Address
City State Zip

ALTERNATIVE NO. 2

ACKNOWLEDGEMENT BY NOTARY PUBLIC

State of Alaska ________________ Judicial District
On this ____ day of ___________________, in the year ______________, before me,
__________________________________________ (name of notary public) appeared
__________________________________________, personally known to me (or proved to me on the
basis of satisfactory evidence) to be the person whose name is subscribed to this instrument,
and acknowledged that the person executed it.

(Seal)

____________________________________________
Signature of Notary Public

Courtesy of Representative Bruce Weyhrauch
Alaska State Capital
Juneau, Alaska 99801

907-465-3744

Paid for by funds available to Rep. Weyhrauch under AS 24.10.110.

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